You will be working with the physicians and others in your practice on a wide range of letters, reports, medical forms, and other written materials. Medical writing is a form of technical writing using scientific and clinical terms along with Standard English words and phrases. In many documents, physicians and others use myriad abbreviations, symbols, and grammatical shortcuts. You will need to interpret this information and convey it accurately and clearly in your writing. This review will cover some fundamentals of effective writing, including sentence structure, punctuation, and spelling tips. Written work completed by you and the other members of your medical office are a reflection of the quality of care that you provide. In addition, it is likely that the bulk of your written work will be related to patient health information and, therefore, will be a part of the legal record.
A sentence conveys a thought or idea in writing. There are many types of sentences, but all have two basic elements: a subject (noun) and a predicate (verb), along with the words that describe the verb. The subject conveys the who in the sentence and the predicate conveys the what, or the action or activity that is happening. If a sentence does not have both, it is considered a sentence fragment, and it does not convey a meaningful thought. Sentences can be simple and contain only one subject and one predicate, or complex and contain more than one of each. However, in writing complex sentences, it is important to make sure that you do not convey too many thoughts or you will create a run-on sentence. If you write a letter or a document, you should begin with a topic sentence that introduces the purpose and scope of the document. Next, you want to convey important ideas or findings in subsequent sentences.
For sentences to be clear, some general rules to follow are to tighten up wordy sentences. Avoid redundancies such as basic essentials when writing. If you have time, you may want to prepare a rough draft and have someone else review it for clarity and accuracy. Make sure that the verb tenses agree throughout the document. In addition, the sentences should have the same point of view. A more casual approach may be in the first person such as, “you will need to take the medicine daily.” A more formal point of view may be in the third person and state, “patients will need to take the medication daily.” The purpose of the document should guide your use of style in sentences.
In this section, you will review the most common forms of punctuation and their correct usage. If in doubt, refer to a style manual or grammar usage text as a reference. Correct use of punctuation will increase the effectiveness of your written communication.
End-of-sentence punctuation includes periods, question marks, and exclamation points. Each tells your reader that the thought is ending and a new one will begin. In addition, periods are used after many abbreviations such as M.D. or Ph.D. When abbreviating names of states or two or more initials using all capital letters, like USA, periods may or may not be used. You should be consistent in using periods for these and other abbreviations within a document.
Commas are the most common punctuation form used in writing. They are used for a variety of reasons, including those in the following list.
A colon (:) is inserted after an independent clause in a sentence. It is used to alert the reader to the information that is listed or quoted following the clause. A colon should be used as in the following example: A routine exam includes the following: a health history, a physical examination, and a series of laboratory tests. A colon is also used in a formal business letter after the salutation (for example, Dear Sir/Madam:).
Semicolons (;) are used between items in a series that are joined together in a sentence. They are also used between independent clauses that are not joined by a conjunction. Most often, clauses are joined by conjunctions such as and, but, or, nor, or so. If you do not include these terms to link clauses in a sentence, then a semicolon can be used to separate the clauses. In the following sentence, the semicolon is used instead of the word and: The patient filled out the form; the physician read it.
Apostrophes (’) are used to indicate possession and contractions. Possessive nouns generally indicate ownership, as in the doctor’s office or the assistant’s desk. If the noun is plural and ends in the letter s, the apostrophe should follow the word.
In contractions, the apostrophe takes the place of the missing letters. For example, in the phrase, don’t \do not\ eat or drink before the test, the apostrophe takes the place of the letter o in the word not.
Apostrophes are also commonly used to abbreviate the first two digits in a year or decade. For example, she graduated in the class of ’59, or she is from the ’60s.
It is likely that you will be preparing many documents on a computer, using word processing software. Spell-checking and grammar-checking tools are embedded in these products and should be used routinely. However, spell-checkers do not flag improper use of common words like its and it’s, nor do they note incorrect use of words like do and due. You must take care in proofreading your documents for accuracy. Make use of a medical dictionary to look up terms and to ensure that correct spelling is used. It is a good idea to have a list of common medical terms that are unique to your practice available as a reference.
Ensure that your writing is concise, precise, and clear to the reader. Spell out medical symbols and abbreviated words. The medical community has recently been challenged to avoid excessive use of some abbreviations, as they can be linked to serious medical errors in medications and treatments. Your job will be to translate abbreviations and symbols into sentences for reports and other clinical documents. Your office should have a list of accepted abbreviations that are frequently used. If the document you are preparing is handwritten, make sure your handwriting is legible and signed and dated with your name and title. It is a good idea to have a style manual and a medical dictionary available as reference tools.